Pro Forma Curriculum Vitae
(Provisional Recognition of Prior Learning)
1. Personal Details:
Family Name (Surname)
Given Names (First and
middle)
Medical Registration
number
Date of Birth
Gender
Postal Address
Phone
dd/mm/yyyy
Male
Female
(H)
(W)
(M)
(Fax)
Contact email address
2. Residency/Citizenship:
I am an Australian citizen
I am a permanent
resident of Australia
I am a temporary resident
(either skilled migration
or business visas – no
student visas)
Yes
Yes
No
No
Yes
No
3. Medical Registration:
Current & All Previous Medical Licensing Authorities:
Type of registration
(indicate if licensed
to practice as
specialist or not)
Date (from/to)
Registering
authority
dd/mm/yyyy to
dd/mm/yyyy
Australian Medical Licensing assessments completed:
(if holding Limited Registration):
Please list all relevant assessments completed
Date
Assessment
IELTS or equivalent
MCQ
Independent Pathway Pro Forma CV – November 2014
Any
restrictions/conditions
or undertakings?
4. Qualifications:
Primary Medical Qualification (MBBS or equivalent):
Qualification title:
Year Awarded
Country of Training:
Medical School:
Controlling University:
Was a period of internship included in qualification?
Yes
If yes, what dates? (include month/year) From
To
Certified copy of
Yes
No
Certificate provided
No
Specialist Qualification (if applicable):
Qualification title:
Year Awarded:
Country of Training:
Institution Awarding
qualification:
Duration of training in
years
Certified Copy of
Certificate provided
Yes
No
Additional Qualifications (if applicable):
Qualification title:
Year Awarded:
Country of Training:
Institution Awarding
qualification:
Certified Copy of
Certificate provided
Yes
No
5. Training:
Core Clinical Training
Please list all core clinical terms undertaken within the Australian Health System
Dates
Term Undertaken, Hospital
Completed
Evidence
provided
dd/mm/yyyy to
Anaesthetics:
Yes
No
Yes
dd/mm/yyyy
dd/mm/yyyy to
Emergency Medicine:
Yes
No
Yes
dd/mm/yyyy
dd/mm/yyyy to
General Medicine:
Yes
No
Yes
dd/mm/yyyy
dd/mm/yyyy to
Obstetrics & Gynaecology:
Yes
No
Yes
dd/mm/yyyy
dd/mm/yyyy to
Paediatrics:
Yes
No
Yes
dd/mm/yyyy
dd/mm/yyyy to
Surgery:
Yes
No
Yes
dd/mm/yyyy
Independent Pathway Pro Forma CV – November 2014
No
No
No
No
No
No
Certificates & Courses:
Please list all relevant courses attended and certificates gained
Date
Course/Certificate
Copies of certificates
provided
Yes
Yes
Yes
No
No
No
Specialist Examinations (if applicable):
Please include details of examinations taken (MCQ, Viva Voce, Clinical)
Dates
Institution
Specialty/
Components of
Copies of
Sub-Specialty
Examination
certificates
provided
Yes
Yes
Yes
No
No
No
6. Detailed Employment History:
Please list all employment in reverse chronological order starting with your current or
most recent position.
Clearly identify your intern year (postgraduate year 1) and detail rotations undertaken
also identify any years undertaken as part of a specialist training program.
ACRRM requires basic rotations or other comparable experience in general medicine,
general surgery, emergency medicine, paediatrics, anaesthetics and obstetrics and
gynaecology. Ensure that experience in these disciplines is detailed below.
Provide full locations of all positions (street, suburb, city/town, state, country) and brief
description of day to day duties.
Please ensure that you list the dates you commenced and ceased employment in
each position (in month and year format MM/YYYY). Also provide an explanation for
any gaps that appear in your employment history.
Independent Pathway Pro Forma CV – November 2014
Employment:
(if there insufficient space to include all your employment history please provide details on
earlier employment on a separate page)
Do you have VMO
Yes
No
rights as part of your
current position?
How often are you on
a roster for VMO?
What are your duties
as VMO?
Start/end dates
to
Hours per week
Total number weeks
FTE
Institution/Hospital
Discipline
Position title
Supervisor
Location (town, state,
country)
Duties
Certified evidence of employment
provided
Certified evidence of satisfactory
performance provided
Start/end dates
Yes
No
Yes
No
to
Hours per week
Total number weeks
FTE
Institution/Hospital
Discipline
Position title
Supervisor
Location (town, state,
country)
Duties
Certified evidence of employment
provided
Certified evidence of satisfactory
performance provided
Yes
No
Yes
No
Independent Pathway Pro Forma CV – November 2014
Start/end dates
to
Hours per week
Total number weeks
FTE
Institution/Hospital
Discipline
Position title
Supervisor
Location (town, state,
country)
Duties
Certified evidence of employment
provided
Certified evidence of satisfactory
performance provided
Start/end dates
Yes
No
Yes
No
to
Hours per week
Total number weeks
FTE
Institution/Hospital
Discipline
Position title
Supervisor
Location (town, state,
country)
Duties
Certified evidence of employment
provided
Certified evidence of satisfactory
performance provided
Start/end dates
Yes
No
Yes
No
to
Hours per week
Total number weeks
FTE
Institution/Hospital
Discipline
Position title
Supervisor
Location (town, state,
country)
Duties
Certified evidence of employment
provided
Certified evidence of satisfactory
performance provided
Yes
No
Yes
No
Independent Pathway Pro Forma CV – November 2014
Start/end dates
to
Hours per week
Total number weeks
FTE
Institution/Hospital
Discipline
Position title
Supervisor
Location (town, state,
country)
Duties
Certified evidence of employment
provided
Certified evidence of satisfactory
performance provided
Start/end dates
Yes
No
Yes
No
to
Hours per week
Total number weeks
FTE
Institution/Hospital
Discipline
Position title
Supervisor
Location (town, state,
country)
Duties
Certified evidence of employment
provided
Certified evidence of satisfactory
performance provided
Start/end dates
Yes
No
Yes
No
to
Hours per week
Total number weeks
FTE
Institution/Hospital
Discipline
Position title
Supervisor
Location (town, state,
country)
Duties
Certified evidence of employment
provided
Certified evidence of satisfactory
performance provided
Yes
No
Yes
No
Independent Pathway Pro Forma CV – November 2014
Start/end dates
to
Hours per week
Total number weeks
FTE
Institution/Hospital
Discipline
Position title
Supervisor
Location (town, state,
country)
Duties
Certified evidence of employment
provided
Certified evidence of satisfactory
performance provided
Start/end dates
Yes
No
Yes
No
to
Hours per week
Total number weeks
FTE
Institution/Hospital
Discipline
Position title
Supervisor
Location (town, state,
country)
Duties
Certified evidence of employment
provided
Certified evidence of satisfactory
performance provided
Start/end dates
Yes
No
Yes
No
to
Hours per week
Total number weeks
FTE
Institution/Hospital
Discipline
Position title
Supervisor
Location (town, state,
country)
Duties
Certified evidence of employment
provided
Certified evidence of satisfactory
performance provided
Yes
No
Yes
No
Independent Pathway Pro Forma CV – November 2014
7. Continuing Professional Development activities:
Please include details of any continuing professional development activities you have
undertaken in the previous three years or provide a certificate from your Medical
College detailing activities:
Verification Statement:
I verify that the information contained within this Curriculum Vitae is true and
correct as at
Name:
Date:
Independent Pathway Pro Forma CV – November 2014